[Evaluation of the impact and efficiency of high-fidelity simulation for neonatal resuscitation in midwifery education]. / Évaluation de la simulation haute-fidélité dans la formation initiale à la réanimation en salle de naissance chez les étudiants sages-femmes.

BACKGROUND: Prompt initiation of appropriate neonatal resuscitation skills is critical for the neonate experiencing difficulty transitioning to extra-uterine life. Expertise in neonatal resuscitation is essential for personnel involved in the care of newborns, above all for midwives who are sometimes alone to initiate the first resuscitation. The use of simulation training is considered to be an indispensable tool to address these challenges, not only in continuing education but also in midwifery education. OBJECTIVE: The aim of this study was to evaluate the impact and efficiency of high-fidelity simulation for neonatal resuscitation in midwifery education. METHODS: This was a prospective monocentric study conducted in the Angers university hospital between October and December 2012 and included two groups of midwifery students (n=40) who received high-fidelity simulation as part of their basic midwifery education. Participants' perceptions of the knowledge, skills, and confidence gained following training in high-fidelity simulation for neonatal resuscitation were determined using a pre-/post-test questionnaire design completed during the training and also several months after the course, as well as after the students had begun working. A satisfaction survey to evaluate this training was also completed at the same time. RESULTS: With a good participation rate (67.5%), the survey showed a high degree of satisfaction among the participants. This training was described as facilitating their hire in one third of cases. A significant increase in self-assessment of skills scores was observed between the pre-test and post-test (P<0.001), the pre-test and the distance test (P<0.001), and the post-test and distance test (P=0.007). Although a decrease in the median score was observed on the knowledge questionnaire given as a post-test, this median remained significantly higher than that obtained on the pre-test (P=0.03). CONCLUSION: The significant improvement in knowledge during the session and its preservation after a few months confirmed the efficacy of this teaching method. The simulation training increased the participants' perceptions of their knowledge, skills, and confidence in conducting neonatal resuscitation. These preliminary results are very encouraging and argue in favor of generalizing this teaching method. However, this training could be more profitable if it was proposed earlier in the midwifery curriculum and organized with a multidisciplinary team (pediatric and anesthesia residents).

[Update on vaccine research. Proceedings of the 15th annual conference on vaccine research organized by the National Foundation for Infectious Diseases]. / Actualités en matière de recherche vaccinale. Compte-rendu de la 15(e) conférence annuelle sur la recherche vaccinale organisée par la National Foundation for Infectious Diseases.

Every year, the National Foundation for Infectious Diseases brings together more than 300 participants to review progress in vaccine research and development and identify the most promising avenues of research. These conferences are among the most important scientific meetings entirely dedicated to vaccine research for both humans and animals, and provide a mix of plenary sessions with invited presentations by acknowledged international experts, parallel sessions, poster sessions, and informal exchanges between experts and young researchers. During the Fifteenth Conference that took place in Baltimore in May 2012, various topics were addressed, including the scientific basis for vaccinology; exploration of the immune response; novel vaccine design; new adjuvants; evaluation of the impact of newly introduced vaccines (such as rotavirus, HPV vaccines); vaccine safety; and immunization strategies. The new techniques of systems biology allow for a more comprehensive approach to the study of immune responses in order to identify correlates of protection and to design novel vaccines against chronic diseases such as AIDS or malaria, against which natural immunity is incomplete.

[Survival and neurologic outcomes after extremely preterm birth]. / Survie et devenir neurologique à l'âge corrigé de 2 ans des enfants nés extrêmement prématurés.

OBJECTIVE: To determine survival and neurologic outcomes at 2 years after extremely preterm birth. METHODS: A retrospective study including all births (live births and stillbirths) and late terminations of pregnancy at 22-26 completed weeks' gestation in the Pays de la Loire region of France in 2004-2005. We determined survival rates, factors associated with death in neonatal intensive care units (NICUs), and neurologic assessment at the corrected age of 2 years by the Loire Infant Follow-up Team (LIFT). RESULTS: A total of 444 births were recorded, 37% were medical terminations of pregnancy, 34% were stillbirths, and 29% were live births. Among the 129 hospitalized live births, the survival rate at discharge was 47% (13.7% of all obstetrical outcomes). Mortality decreased with gestational age (P=0.02) and cesarean section (P=0.03). Mortality was higher after extrauterine transport (OR=4.44; 95% CI [1.63-12.12]; P<0.01) and in cases of grade III or IV intraventricular hemorrhage (OR=13.7; 95% CI [4.85-38.5]; P<0.01). The NICU where infants were admitted, gender, multiple birth, and birth weight did not alter mortality. At the corrected age of 2years, 26% of survivors had a normal neurologic assessment, whereas 31% had severe abnormal neurologic outcome. CONCLUSION: In our study, survival and neurologic outcomes of extremely preterm infants were poor. An extended neurologic follow-up seems necessary for these children, in order to diagnose and manage any subsequent disability.

[Current events in vaccination]. / Actualités en matière de vaccination.

The annual meeting of the Infectious Disease Society of America (IDSA) ; which brought together nearly 5000 participants from over 80 countries in Vancouver, Canada, October 21 to 24, 2010 ; provided a review of the influenza (H1N1) 2009 pandemic, evaluated vaccination programmes and presented new vaccines under development. With 12,500 deaths in the United States in 2009-2010, the influenza (H1N1) 2009 pandemic was actually less deadly than the seasonal flu. But it essentially hit the young, and the toll calculated in years of life lost is high. The monovalent vaccines, whether live attenuated or inactivated with or without adjuvants, were well tolerated in toddlers, children, adults and pregnant women. In order to protect infants against pertussis, family members are urged to get their booster shots. The introduction of the 13-valent Pneumococcal conjugated vaccine in the beginning of 2010 may solve - but for how long ? - the problem of serotype replacement, responsible for the re-increasing incidence of invasive Pneumococcal infections observed in countries that had introduced the 7-valent vaccine. The efficacy of a rotavirus vaccine has been confirmed, with a reduction in hospitalization in the United States and a reduction in gastroenteritis-related deaths in Mexico. In the United States, vaccination of pre-adolescents against human papillomavirus (HPV) has not resulted in any specific undesirable effects. Routine vaccination against chicken pox, recommended since 1995, has not had an impact on the evolution of the incidence of shingles. Vaccination against shingles, recommended in the United States for subjects 60 years and over, shows an effectiveness of 55 %, according to a cohort study (Kaiser Permanente, Southern California). Although some propose the development of personalized vaccines according to individual genetic characteristics, the priority remains with increasing vaccine coverage, not only in infants but also in adults and the elderly. Vaccine calendars that cover a whole lifetime should be promoted, since the vaccination of adults and seniors is a determining factor of good health at all ages.

[Current events in vaccination]. / Actualités en matière de vaccination.

The annual meeting of the Infectious Disease Society of America (IDSA); which brought together nearly 5000 participants from over 80 countries in Vancouver, Canada, October 21 to 24, 2010; provided a review of the influenza (H1N1) 2009 pandemic, evaluated vaccination programmes and presented new vaccines under development. With 12,500 deaths in the United States in 2009-2010, the influenza (H1N1) 2009 pandemic was actually less deadly than the seasonal flu. But it essentially hit the young, and the toll calculated in years of life lost is high. The monovalent vaccines, whether live attenuated or inactivated with or without adjuvants, were well tolerated in toddlers, children, adults and pregnant women. In order to protect infants against pertussis, family members are urged to get their booster shots. The introduction of the 13-valent Pneumococcal conjugated vaccine in the beginning of 2010 may solve--but for how long?--the problem of serotype replacement, responsible for the re-increasing incidence of invasive Pneumococcal infections observed in countries that had introduced the 7-valent vaccine. The efficacy of a rotavirus vaccine has been confirmed, with a reduction in hospitalization in the United States and a reduction in gastroenteritis-related deaths in Mexico. In the United States, vaccination of pre-adolescents against human papillomavirus (HPV) has not resulted in any specific undesirable effects. Routine vaccination against chicken pox, recommended since 1995, has not had an impact on the evolution of the incidence of shingles. Vaccination against shingles, recommended in the United States for subjects 60 years and over, shows an effectiveness of 55%, according to a cohort study (Kaiser Permanente, Southern California). Although some propose the development of personalized vaccines according to individual genetic characteristics, the priority remains with increasing vaccine coverage, not only in infants but also in adults and the elderly. Vaccine calendars that cover a whole lifetime should be promoted, since the vaccination of adults and seniors is a determining factor of good health at all ages.

[Linear insertion of atrioventricular valves (Livav): echocardiographic diagnosis, reliability and prevalence in the general population]. / Insertion linéaire des valves auriculoventriculaires (Ilvav): fiabilité du diagnostic échographique et prévalence dans une population sans trisomie 21.

OBJECTIVES: Assess the reliability of prenatal diagnosis of linear insertion of atrioventricular valves (Livav) by echocardiography as well as estimate Livav's prevalence in a population without Down syndrome. PATIENTS: One hundred and twenty-three fetuses of whom 113 were explored before and after birth and 631 consecutive out-patients explored in cardiopediatric unit. METHODS: Determination of the likehood ratio (LHR+ and LHR-) of Livav prenatal diagnosis. Evaluation of the consistency between pre- and postnatal diagnoses as well as between two observers after birth (Kappa index). Prevalence study according to the presence of Down syndrome, cardiac malformation or others abnormalities. RESULTS: LHR+ value was 6.17 and LHR- value was 0.30 for echographic Livav prenatal diagnosis. Consistency was low between pre- and postnatal diagnoses (Kappa = 0.57) and higher between two observers after birth (Kappa = 0.79). Livav prevalence was 2 to 5% in a population without Down syndrome but 15% when associated with a cardiac malformation. Seventy-eight percent Down syndromes had either Livav or AVSD. CONCLUSION: Livav echographic prenatal diagnosis is difficult, for it generates many false positives. Livav is not specific of Down syndrome and can be found relatively frequently in other subjects.

[Eleven cases of early neonatal sudden death ou near death of full term and healthy neonates in maternity wards]. / Onze cas de malaises graves de nouveau-nés à terme et présumés sains dans les premières heures de vie.

OBJECTIVE: Sécurité naissance-Naître ensemble des Pays-de-la-Loire network organized a survey to evaluate the incidence rate of early neonatal sudden death or near death syndrome for the full term and healthy presume neonates. METHOD: Maternity wards are declared apparent life-threatening events and deaths from 2001 to 2006. Certain cases and probable cases were defined. Incidence rate have been calculated with births in maternity wards during period... RESULTS: Eleven apparent life-threatening events are observed with 7 deaths during five and half years. The incidence rate was one apparent life-threatening events for 26,000 births and one death for 40,000 births, with certain cases for 41,000 births and probable cases for 71,000 births. All kind of maternities were involved. Nothing very special could be noticed about pregnancies and deliveries. Five times on eight well known cases, the newborn was in skin to skin contact with heir mother at the moment of the event, once in her arms and once in the delivery room, far from the mother, at three minutes of life. Twice on four well known cases, newborns were lying on their belly. A baby has been considered as dead at the maternity, ten have been transferred to care unit, and six died in the ward. CONCLUSION: Without systematic survey in France, it's not easy to say if the incidence of this type of event have increased, and if their happening is linked with skin-to-skin practices at the birth. In Sécurité naissance-Naître ensemble des Pays-de-la-Loire from September 2006, prevent measures have been suggested in all maternities in the recommendation on care to normal newborns. A systematic study with a standard questionary has been organized in region area to notice apparent life-threatening events and neonatal sudden deaths, and we could hope a systematic prospective survey in France.

[Central-venous-catheter-related bacteremia in neonatalogy]. / Bactériémies nosocomiales sur cathéters veineux centraux en néonatologie.

OBJECTIVE: The aim of this retrospective study was to identify the risk factors for catheter-associated bloodstream infection (CABSI) in neonates. METHOD AND RESULTS: Fifteen episodes of CABSI occurred in 108 central catheters over a period of one year (2002). The univariate analysis risk factors were birth weight (1.064 vs 1.413 g; P<0.001), gestation age (28 vs 31 weeks; P<0.001), blood transfusion (8/15 vs 3/34; P<0.01), corticosteroids (7/15 vs 3/34; P<0.01), nasal CPAP duration (13.6 vs 2 days; P<0.01). Nasal CPAP duration was the only risk factor independently associated with CASBI (OR=1.2, 95% confidence interval=1.09-1.5) in the multivariate logistic regression analysis. CONCLUSIONS: The risk of infection associated with low birth weight is multifactorial suggesting that host-related factors are important. Prevention remains difficult and a policy of strict aseptic catheter care must be promoted.

[Effectiveness of an informative report on the prevention of nosocomial bloodstream infections in a neonatal intensive care unit]. / Prévention des septicémies nosocomiales sur cathéters veineux centraux dans une unité de réanimation néonatale: impact d'une procédure d'information.

OBJECTIVE: Few studies have evaluated the impact of an information and prevention process specifically aimed at neonatalogists and nurses working in a neonatal intensive care unit (NICU) towards the prophylaxis of nosocomial bloodstream infections. Our objective was first to analyze nosocomial infections within our unit, and secondly to evaluate the impact of a monthly report providing information related to the number and characteristics of such infections. PARTICIPANTS AND METHODS: A prospective study was performed in the NICU of Angers University Hospital during 2 six-month periods. All cases of nosocomial bloodstream infections and their characteristics were analyzed. We then published a nosocomial infections report every month during the second period, in order to inform the medical staff and nurses of the results. The impact of the information and prevention process was evaluated by comparing the results between the 2 periods. We also assessed the staff's interest by questionnaire. RESULTS: Two hundred and fifty-four (first period) and 240 (second period) patients were included. A decrease in the specific incidence rate and density of catheter related bloodstream infections was observed between the 2 periods, especially for preterms with a birth weight<1000 g and gestational age<28 SA (P<0.01). Coagulase negative Staphylococcus was identified in 82.3% and 62.5% of cases respectively. 54% of the members of staff expressed their concerns related to the findings and were very interested to read about the observations made during the study. CONCLUSION: This original process seems to be both effective and inexpensive, and can be easily reproduced to decrease the frequency of bloodstream infections in NICU. However, its long-term impact still needs to be evaluated.

Prophylactic ibuprofen versus placebo in very premature infants: a randomised, double-blind, placebo-controlled trial.

BACKGROUND: Patent ductus arteriosus is a common complication of prematurity that frequently requires surgical or medical treatment. The benefit of prophylactic treatment by indometacin, a cyclo-oxygenase inhibitor, remains uncertain compared with curative treatment. This benefit could be improved with ibuprofen, another cyclo-oxygenase inhibitor with fewer adverse effects than indometacin on renal, mesenteric, and cerebral perfusion. We aimed to compare prophylactic and curative ibuprofen in the treatment of this abnormality in very premature infants. METHODS: We did a randomised controlled trial in infants younger than 28 weeks of gestation, who were randomly assigned to receive either three doses of ibuprofen or placebo within 6 h of birth. After day 3, symptomatic patent ductus arteriosus was treated first by open curative ibuprofen, then back-up indometacin, surgery, or both. The primary endpoint was need for surgical ligation. Analysis was per protocol. FINDINGS: The study was stopped prematurely after 135 enrollments because of three cases of severe pulmonary hypertension in the prophylactic group. 65 infants received prophylactic ibuprofen, and 66 received placebo. Prophylaxis reduced the need for surgical ligation from six (9%) to zero (p=0.03), and decreased the rate of severe intraventricular haemorrhage from 15 (23%) to seven (11%) (p=0.10). However, survival was not improved (47 [71%] placebo vs 47 [72%] treatment, p=1.00), because of high frequency of adverse respiratory, renal, and digestive events. INTERPRETATION: In premature infants, prophylactic ibuprofen reduces the need for surgical ligation of patent ductus arteriosus, but does not reduce mortality or morbidity. Therefore, it should not be preferred to early curative ibuprofen.

Pain management in French neonatal intensive care units.

UNLABELLED: The aim of this study was to investigate pain management in neonatal intensive care units (NICUs) in France and to identify factors associated with variability across units. A questionnaire sent to 143 heads of level II or III NICUs investigated the use of pain scores, pain management organization and pharmacological treatment in five clinical situations (endotracheal intubation, prolonged mechanical ventilation, acute stage of necrotizing enterocolitis, central venous catheter insertion and cephalhaematoma). The response rate was 81%. Among the 35 (30%) units that used no pain scores, 40% ascribed this to lack of knowledge. Factors associated with failure to use pain scores were level II status, no university affiliation, no surgical patients and neonatal patients only. Among the units that scored pain, 78% used valid scores for acute pain and 73% for prolonged pain. Written guidelines were available for acute pain in 65% of units and for prolonged pain in 36%. The rate of pharmacotherapy use varied widely across the five clinical situations studied (from 16 to 77%) and across units for a given clinical situation. Also extremely variable were the regimens used in each situation and the dosages of analgesics and sedatives. Only 11% of units adjusted dosages to gestational age. CONCLUSION: Pain assessment was performed in the most French NICUs, but a strong heterogeneity for pain treatment was observed. Reference to recently published pain management guidelines and new randomized trials could be useful to optimize pain treatment in NICUs.

Pulmonary hypertension after ibuprofen prophylaxis in very preterm infants.

We report three cases of severe hypoxaemia after ibuprofen administration during a randomised controlled trial of prophylactic treatment of patent ductus arteriosus with ibuprofen in premature infants born at less than 28 weeks of gestation. Echocardiography showed severely decreased pulmonary blood flow. Hypoxaemia resolved quickly on inhaled nitric oxide therapy. We suggest that investigators involved in similar trials pay close attention to pulmonary pressure if hypoxaemia occurs after prophylactic administration of ibuprofen.

[Gravely ill newborns (excluding greatly premature) in 1986 and 1995 in three deparments of Pays de la Loire]. / Les nouveau-nés gravement malades (grande prématurité exclue) en 1986 et en 1995 dans trois départements des Pays de la Loire.

AIM: Evaluation of the progress in the treatment of seriously ill newborn infants under hospital care over the nine-year period from 1986 to 1995 in three departments of the Pays de la Loire region in France. POPULATION AND METHODS: The category of seriously ill newborn infants included only infants born after at least 32 weeks of gestation and having a Cullen severity score higher than 2. The two groups of seriously ill newborn infants at risk in 1986 and 1995 were first compared to a control group of healthy newborn babies delivered during the same years. The two groups were then compared with each other. RESULTS: In 1986 and 1995, the numbers of births were respectively 32,876 and 29,446, and the numbers of seriously ill newborn infants under hospital care were respectively 307 and 245. However, between 1986 and 1995 the risk factors as well as the causes of morbidity had changed. The average period of hospitalization decreased by five days. The mortality rate dropped from 0.16% to 0.09% (P < 0.05) and the number of serious complications decreased from 0.07% to 0.03% (P < 0.05). CONCLUSION: The improvement in the care of seriously ill newborn infants between the two reference periods, 1986 and 1995, may be attributed not only to technical progress but also to a better organization of the perinatal care in our region.

[Fetal and neonatal mortality from 22 weeks of amenorrhea in the Loire area]. / La mortalité foetale et néonatale à partir de 22 semaines d'aménorrhée en Pays de la Loire.

BACKGROUND: The Pays de Loire has a low perinatal mortality indicators among French regions but this could be due to under-notification. OBJECTS: To explore this hypothesis we undertook a survey in order to identify all fetal and neonatal deaths occurring at a gestionnal age of 22 weeks or more. We also tried to examine and analyze the causes of death. METHODS: All maternity (26) and neonatal wards (5) in the region took part in the survey in 1995. Clinicians were asked to fill out a questionnaire for all deaths occurring from gestational age (GA) 22 weeks and/or concerning a birthweight of a least 500 g. Only perinatal deaths related to parents living in the Pays de Loire were included in the study. RESULTS: Two hundred and sixty seven perinatal deaths were identified out of a total 29,440 births (9.1 /1000). Eighty three (2.8 /1000) were termination of pregnancy for medical reasons, of which 82% were motivated by chromosomic illness. Ninety-nine stillbirths fell (3.4 /1000) into two GA periods: 24 to 27 weeks (20%) and 38 to 41 weeks (2%). The cause of stillbirths remained unknown in 50% of cases despite a post-mortem examination rate of 87%. There were 29 deaths (1 /1000) in the immediate per and post-partum, 40% of which occurred at GA 22 to 25 weeks. Another 38% occurred at GA 36 to 40 weeks and these were related to undectected malformations or infections. Neonatal and intensive care units reported 56 neonatal deaths (1.9 /1000). GA was under 33 weeks for 44% of them. Deaths were caused by usual complications of severe prematurity, neurologic diseases and malformations. Thirty-two percent of total deaths were not notified to the French Authority: 25% of deaths for termination of pregnancy for medical reasons and 7% for stillbirths and per and post partum deaths. CONCLUSION: This survey suggests that the Pays de Loire perinatal mortality indicators remained low compared with other French regions, even after adjustment for this under notification. This casts doubts on the validity of perinatal mortality monitoring based on official notifications. The cause may lie in the inadequacy of legislation of the particular circumstances of perinatal deaths.